Medicaid
Covered with requirementsNo additional clinical requirements are listed beyond the diagnosis.
Qualification pathways
You can qualify through any one of these.
GIP/GLP-1 Special PA for T2DM — stabilized on requested product
All of:
- FDA approved diagnosis of type 2 diabetes mellitus
- Member is currently stabilized on the requested product (documentation must be provided)
GIP/GLP-1 Special PA for T2DM — cannot use lower-tiered GLP-1/GIP-GLP-1 agonists
All of:
- FDA approved diagnosis of type 2 diabetes mellitus
- Patient-specific, clinically significant reason (other than convenience) why member cannot use all available lower-tiered GLP-1 or GIP/GLP-1 agonists
Documentation to bring
- Documentation of FDA approved type 2 diabetes mellitus diagnosis
- Documentation that member is currently stabilized on the requested product OR patient-specific, clinically significant reason why member cannot use all available lower-tiered GLP-1 or GIP/GLP-1 agonists
Policy note: Mounjaro (tirzepatide) appears in the GIP/GLP-1 Agonists table as a Tier-2 (Special PA) product. The Special PA criteria for GLP-1 Agonists and GIP/GLP-1 Agonists apply. The underlying Tier-2 antidiabetic criteria require T2DM diagnosis and at least 3-month metformin trial (unless intolerable) or a clinically significant reason. A clinical exception applies for medications with a unique FDA approved indication not covered by all Tier-2 and Tier-3 GLP-1 or GIP/GLP-1 agonists. No quantity limits specified in this document for Mounjaro specifically.
verified June 4, 2026 · source: policy-385.html